Employee Name (required)
Date (required)
Driver's License # (required)
State (required)
License Plate # (required)
Make/Model (required)
I understand that I may be required to use my personal vehicle to transport individuals during working hours.
When transporting individuals, I will at all times practice safe driving techniques and strictly adhere to all traffic safety laws.
When transporting individuals, I will ensure that all vehicle occupants are wearing seatbelts.
I will provide Convenient Care with a copy of my current driver's license and each time my license is renewed I will provide Convenient Care with a copy.
I will maintain liability coverage during my employment and provide Convenient Care with insurance documentation, as needed, to verify automobile coverage.
During scheduled working hours I will use my personal vehicle for work-related tasks only.
I will transport individuals only in the vehicle identified above. If at any point I change vehicles, I will complete a new Vehicle Usage Agreement.
I will immediately notify Convenient Care of any and all traffic violations, or changes in insurance coverage, which may affect my ability to use my personal vehicle to perform job duties.
I will at all times keep my vehicle in safe operating condition, including but not limited to, and ensuring the following:
Rear view mirror and side mirrors present and in good working condition
Headlights (bright and dim) in proper working order
Stop, parking, and turn signals (front and rear) work properly
Windshield wipers work and blades are in good condition
Tires have good tread and are free from damage (no breaks, cuts, or bulges)
Seatbelts are free from wear and tear and working properly
Working horn
Brakes are in proper working order
The interior and exterior of the vehicle are in safe condition
I hereby certify that I understand and will adhere to the guidelines detailed above in Section A. I also understand that failure to do so may result in disciplinary action.
Signature (required)